Toe Wai Aung

310-***-**** ad2npg@r.postjobfree.com Gadsden, AL

PROFESSIONAL SUMMARY

Certified Coding Specialist (CCS) certified clinical documentation improvement professional with over 8+ years of experience. Possesses medical background knowledge from surgical techniques to current medical principles and guidelines through a foreign medical program. Extensive experience in providing Epic Systems and live support training to healthcare professionals. Works well across a multitude of work environments while ensuring accuracy and compliance completeness of patient medical records.

WORK EXPERIENCE

Riverview Regional Medical Center Gadsden, AL

Clinical Documentation Specialist Supervisor/Team Lead November 2016 - Present

• Manage the CDI program by reviewing overall quality and completeness of provider documentation, identifying missing links to accurately reflect patient condition and level of services assigned

• Lead a collaborative team of CDI, Coding, HIM, Case management and UR personnel to minimize denials, improve length of stay and performance for core measures including HACs/ECRIs

Strengthen the query management process by generating well-informed, compliant, credible queries and maintaining timeliness in query response (TAT 2 days) and the following escalation process

• Implemented the Documentation Fallout tool to ensure consistent documentation in patient charts and improved case mix index (CMI) by 0.4, GmLOS and severity of illness and risk of mortality rate

• Provide CDI training for patient care teams including physicians, residents and nurses while promoting habitual documentation procedures

• Lead meetings with executives, physicians, and healthcare professionals to update CDI progress

• Contribute to the planning, development and implementation, and ongoing success of the Clinical Documentation Management Program

• Periodically analyze and report CDI metrics for continuous process improvement to executives and corporate office to ensure overall quality, integrity, and completeness of clinical documentation

Led the DRG Appeals case by conducting research on state and federal laws and statues regarding reimbursement

Riverview Regional Medical Center Gadsden, AL

Clinical Documentation Specialist May 2015 – November 2016

Increased accuracy of documentation resulting in a yearly increase in the Medicare blended rate

Increased the reimbursement on 25% of the charts reviewed while facilitating accurate MD documentation resulting in a DRG (final diagnosis) change

Reviewed patient medical records in EPIC system to ensure accuracy of physician documentation compared to the Medicare approved verbiage

Increased the accuracy of documentation and captured co-morbid conditions to reflect the mortality index of the facility more accurately

Facilitated improvement in the overall quality and completeness of medical record documentation process through the query process

Impacted financial reimbursement through improved quality of clinical documentation

Reviewed medical records for identified payer populations (Medicare, Medicaid, Blue Cross Blue Shield) as directed on admission records and throughout hospitalization period

Barr Clinic Yangon, Myanmar

Volunteer Doctor August - December 2013

Checked up patients and prescribed relevant medications or referred to specialists

Monitored medical treatments, diagnosis, and assessment of patients

Educated patients on prevention and detection of illness by providing resources and materials to the patients and families

Participated in public health and sanitation inspections and provided care instructions

Mandalay General Hospital Mandalay, Myanmar

Intern Doctor in Surgical Ward January – March 2012

Performed therapeutic procedures such as injections, suturing, wound care and infection management

Assisted surgeons during surgery and complicated medical procedures

Performed life-saving procedures (CPR) and sutured head injury patients with scalp lacerations in Neurosurgical Unit

Assisted doctors in treatment of patients with trauma and injuries in Emergency and Trauma Unit

Intern Doctor in Pediatrics Ward July - September 2012

Conducted daily ward rounds for checking progress, monitoring and allowing early discharge of patients under care

Assisted physicians with treatments and monitored patients with childhood diseases and other communicable diseases on daily basis

Worked cooperatively with Department of Preventive and Social Medicine in surveying health and sanitation status data and provided outreach for prevalent childhood diseases

Managed and monitored newborns with serious life-threatening diseases, infections, and congenital defects in Neonatal Care Unit

Intern Doctor in Medical Ward October - December 2012

Assisted in diagnosis and treatment of medical conditions under the supervision of attending physicians

Managed the outpatient unit, hospital admissions, patient progress, treatment, vital signs, laboratory, diagnosis and X-rays

Participated in quality management and improvement efforts to provide patients with the best care

EDUCATION

Bachelor’s of Medicine & Bachelor's of Surgery (M.B, B.S) February 2013

University of Medicine, Mandalay Mandalay, Myanmar

SKILLS

Medical history documentation, Medical Diagnosis and treatment, Patient Assessment and care, Electronic Health Records (EHR), Patient Communication and Education

Clinical Documentation Improvement, ICD-10 Coding, Medical Terminology, Healthcare Compliance

Software: MS Suite, Epic Systems, 3M 360 encoder, 3M 360 Encompass system

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